Mortality review tool

This tool and supporting guidance have been developed to support mental health trusts in securing learning through reviewing the deaths of patients who are currently or have recently been under their care | Royal College of Psychiatrists (RCPsych)

The Royal College of Psychiatrists (RCPsych) has drawn up national guidance, which is made up of a Care Review Tool and guidance on how to use it, for the first time at the request of NHS England.

The guidance focuses on patients with severe mental illness and on four ‘red-flag’ scenarios, including where concerns have been raised by families and carers or where patients have experienced psychosis or had an eating disorder. To ensure any opportunities for learning are not missed, trusts are also encouraged to review a sample of other patients’ deaths, such as those with dementia.

The Tool has been developed to look at care at different phases of a patient’s contact with services, and ensures that good care is able to be recognised, judged and recorded in the same detail as problematic care. The object of the structured judgement review method is to look for strengths and weaknesses in the process of the patient’s care and treatment, to provide information about what can be learned when care goes well, and to identify gaps, problems or difficulties in the care received by the patient.

The tool allows explicit judgements around a patient’s care to be made, with a score given for each phase of care. The aim of this tool is to make it possible for Trusts to screen all deaths of patients in contact with mental health services and, through thematic analysis of a number of completed forms, to:

  1. Determine areas of good care that can be recognised and further developed
  2. Recognise areas where care can be improved

The Care Review Tool and the guidance for using it is published here.

New Digital transformation bulletin


The new Digital transformation bulletin is for anyone with an interest in data, digital technology and services within health and care. Providing a round-up of the latest news, programme updates, events and relevant media coverage in the digital transformation of the NHS.

The bulletin will be published every six weeks, giving a flavour of the depth and breadth of digital work being driven nationally by teams across NHS England, NHS Digital, NHS improvement, the Department of Health and Social Care and beyond. Subscribe now to receive the latest news and developments.

FREE NHS WiFi at Crystal Peaks Medical Centre

NHS England | November 2018 | NHS WiFi at Crystal Peaks Medical Centre

Crystal Peaks Medical Centre is a  GP practice in a busy retail park in Sheffield; it installed NHS WiFi in July 2018,  NHS England have now produced a case study about this innovation and  video interview with Dr Kirsty Gillgrass, a GP Partner at the practice. There are approximately 7,000 patients registered with the practice. It is a training practice with 5 GP partners and a large multi disciplinary primary care team. 

The practice, along with other practices in the neighbourhood, is applying for digital inclusion funding to encourage digitally excluded patients to take charge of their health and wellbeing and make use of patient online services.

Practice staff will encourage patients to sign-up for patient online services while in the waiting room, and staff will be able to use mobile devices to demonstrate to patients how to book appointments online and order repeat prescriptions.

Having access to free WiFi can also reduce anxiety for patients before their appointment. Being able to make good use of their time by accessing emails, checking social media or even downloading an ebook to calm their nerves can improve the patient experience (Source: NHS England).

Empowering NHS leaders to lead

New publication looks at the key challenges faced by executive leaders across the NHS and makes recommendations on how best to support NHS leaders | Department of Health and Social Care

The Department of Health and Social Care has published Empowering NHS leaders to lead. This review, led by Sir Ron Kerr, explores three key challenges faced by executive leaders across the NHS:

  • the expectations and support available
  • alignment of performance expectations at the organisational and system level
  • level of administrative burden placed upon leaders.

The report makes a number of recommendations to address these challenges.

Full document available here

National Record Locator Service

New service will put crucial patient information in the hands of paramedics and mental health nurses | NHS Digital

NHS Digital has launched the new National Record Locator Service.  The new service will enable triage personnel such as mental health nurses and paramedics, who are called to a patient in distress, to find out whether a patient they are treating has a mental health crisis plan and ensure they are offered care in the most appropriate setting.  The service has been launched in beta; first use-case partners will be North West, North East, Yorkshire and London Ambulance Services working with local mental health trusts.

The next phase of development will continue integration with other Local Health and Care Record Exemplars before a full roll-out across the NHS.

Record retrieval for phase one sites is expected by summer 2019 and future use-cases include end of life care, child health, maternity and cancer.

Full detail at NHS Digital

Royal Cornwall Hospital: Improving sepsis screening and treatment

NHS England | November 2018 | Royal Cornwall Hospital: Improving sepsis screening and treatment

A case study from NHS England  shows how the Royal Cornwall Hospital formed a cross-speciality panel and employed a dedicated sepsis nurse to improve patient outcomes.
The  trust recognised that sepsis affected patients at all stages of the patient journey in hospital; from day of admission to awaiting discharge, from clinic visit to post-operative recovery, and therefore a range of specialties had to be represented in drawing up the quality improvement plan. The establishment of a national CQUIN which sampled sepsis screening and treatment from across the hospital population helped to provide impetus towards a trust-wide co-ordinated approach.

The  trust raised mortality to national average and saw an increase in  emergency department assessment for sepsis from 52% to 89% from April 2015 to December 2017.

Timely treatment increased from 49% to 76% in the same period. In-patient assessment for sepsis increased by 8 per cent from 68 per cent to 70 per cent from April 2016 to December  2017 and timely treatment increased from 58 per cent to 80 per cent for these patients. This has contributed to the improvement in patient outcomes (Source: NHS England).

Case study in full at NHS England 

Advice line for GPs saves hours of travel for patients and £100k to be reinvested back into NHS

NHS England | November 2018 | Advice line for GPs saves hours of travel for patients and £100k to be reinvested back into NHS

The Walton Centre in Liverpool – the only specialist hospital trust in the UK dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services-   runs an advice line which means GPs in the Cheshire and Merseyside area can call neuro consultants for fast advice any weekday reducing extra patient appointments. 


So far the service has received 181 calls 37% were resolved by the GP saving £51,698 which over a year saves around £100k.

Programme Director Julie Riley said: “We want to deliver services closer to home and when patients do come into hospital, support them so they can recover and go home quicker. From a patient point of view, we want to work in partnership with them. We, our consultant colleagues and GPs want to support them in self-management, where appropriate – rather than taking a paternalistic approach.”

Read the full case study at NHS England